Application for Employment

Transcription

1 Care at Home With Therapy at Heart! Application for Employment Applicant Name: Address: Daytime Phone: Alternate Phone: Address: Position Applying for: Full-time Part- time PRN What hours are you available to work? List professional licensure you hold: Are you available to work weekends? Yes / No Holidays? Yes / No Desired wage? How did you hear about this company? Who referred you to this company? Have you ever applied for a position with this company before? Yes / No When: Are you at least 18 years of age and legally eligible for work in the U.S? Yes / No If offered employment, when would you be available to work?

2 Pg. 2 Emergency contact information: Name: Relationship: Address: Phone: Employment History: List employers starting with current/ most recent. Employer Name: Address: Phone: Supervisor Name: Date of employment From: To: Position held: Beginning Wage: End Wage: Brief description of job duties: Reason for leaving: May we contact? Yes / No

3 Pg. 3 Employer Name: Address: Phone: Supervisor Name: Date of employment From: To: Position held: Brief description of job duties: Reason for leaving: May we contact? Yes / No Begin Wage: End Wage: Employer Name: Address: Phone: Supervisor Name: Date of employment From: To: Position held: Brief description of job duties: Reason for leaving: May we contact? Yes / No

4 Pg. 4 Are you able to perform the essential functions of the job for which you are applying for, wither with/without reasonable accommodations? Yes / No If no, list functions that cannot be performed: Have you ever been convicted of a felony? Yes / No Do you speak or understand any foreign languages? Yes / No If yes, list: List any other experience, training, qualifications, or skills in which you feel would qualify you for the position applying for would make you especially suited for working with this company? I certify that the information provided on this application is truthful and accurate. I understand providing false or misleading information will be basis for rejection of my application, or if employment commences immediate termination. Applicant Signature Date

5 625 South Earl Avenue Suite D Lafayette, Indiana Phone: (765) Fax: (765) Reference Request Form I, authorize Physiocare Homecare and Hospice to contact former employers regarding my employment. I authorize former employers to fully and freely communicate information regarding my previous employment. I authorize those persons listed as references to fully and freely communicate information regarding my employment. Reference Name: Relationship: Phone: Signature: 1. How long have you known this applicant? 2. What title did the applicant hold during employment? 3. What were dates of employment? From To 4. Describe applicants overall job performance: 5. Were there any attendance issues? Yes/ No 6. Did the applicant work well with others? Yes/ No 7. Is the applicant eligible for rehire with your company? Yes/ No 8. List any other information you feel is relevant to this applicant: Signature of person completing Date

6 625 South Earl Avenue Suite D Lafayette, Indiana Phone: (765) Fax: (765) Reference Request Form I, authorize Physiocare Homecare and Hospice to contact former employers regarding my employment. I authorize former employers to fully and freely communicate information regarding my previous employment. I authorize those persons listed as references to fully and freely communicate information regarding my employment. Reference Name: Relationship: Phone: Signature: 1. How long have you known this applicant? 2. What title did the applicant hold during employment? 3. What were dates of employment? From To 4. Describe applicants overall job performance: 5. Were there any attendance issues? Yes/ No 6. Did the applicant work well with others? Yes/ No 7. Is the applicant eligible for rehire with your company? Yes/ No 8. List any other information you feel is relevant to this applicant: Signature of person completing Date